Cranial nerve III palsy induced by adjuvant capecitabine for cholangiocarcinoma

A man in his 70s with completely resected cholangiocarcinoma started adjuvant treatment with capecitabine chemotherapy. Within 3 weeks he developed complete left-sided ptosis with loss of ocular adduction, elevation and depression. There were no other neurological features; CT and MRI scans of the brain were normal. He had no history of diabetes and blood pressure was reasonably controlled. A diagnosis of capecitabine-induced cranial nerve III palsy was made and no further capecitabine was given. The patient's ptosis improved within a month and there was full resolution within 2 months. He continued with follow-up surveillance CT scans for cholangiocarcinoma. This is the first reported cranial nerve III palsy due to capecitabine, the aetiology of which is uncertain. It is important that clinicians are able to recognise this as a potential complication as capecitabine is commonly given in combination with other agents for various cancer types.